Town of East Hartford
Registrar of Vital Statistics
740 Main Street
East Hartford, CT 06108
(860) 291-7230
APPLICATION FOR DEATH CERTIFICATE
Fee: $20.00 cash or check made payable to “East Hartford Town Clerk.” _________ # of Certified Copies
Death records as of 7/1/1997 restricted as to Social Security number.
VALID GOVERNMENT-ISSUED PHOTO IDENTIFICATION OF APPLICANT IS REQUIRED
Photographic identification may be substituted by at least two of the following documents:
automobile registration, copy of utility bill showing name and address, checking account deposit slip stating
name and address or any other valid government-issued ID.
I AM APPLYING FOR THE DEATH CERTIFICATE OF:
Full Name (first/middle/last)_______________________________________________________________
Place Of Death (town/state)________________________________
Date of Death (mm/dd/yy)__________
Place Of Birth (town/state)_________________________________
Date of Birth (mm/dd/yy)__________
Town of Residence at Date of Death ___________________________________________________
□ a party listed on the death certificate as ____________________________ Relationship _______________________
□ an immediate family member ____________________________________ Relationship _______________________
□ an authorized CT genealogist. (Must produce valid, signed card.)
□ a person authorized by the Dept. of Health & Chief Medical Examiner Rep. (Signed letter on letterhead required.)
□ Other __________________________________________________________________________________________
SIGNATURE of Applicant __________________________________ Phone # __________________
ADDRESS of Applicant (street/town/state)____________________________________________________
If requesting by mail, include: (1) Completed application form, (2) check or money order, (3) Self-addressed,
stamped envelope, (4) legible copy of photo ID. Mail to the address above.
FOR OFFICE USE ONLY:
Date certified copy issued: ___________________ Person issuing copy: ______________________________________
Form(s) of identification used: _________________________________________________________________________
